Asian Cardiovasc Thorac Ann 2004;12:224-226
© 2004 Asia Publishing EXchange Ltd
A New Technique of Fixing a Costal Coaptation Pin after Resection of Rib Segment
Yoshio Tsunezuka, MD,
Tomohisa Iseki, PhD1,
Hideo Sato, MD2,
Norihiko Ishikawa, MD,
Makoto Oda, MD,
Go Watanabe, MD
Department of General and Cardiothoracic Surgery
1 Department of Civil and Constructive Engineering, Kanazawa University
2 Ishikawa Prefectural Central Hospital, Kanazawa, Japan
For reprint information contact: Yoshio Tsunezuka, MD Tel: 81 76 265 2354 Fax: 81 76 222 6833 Email: tsuney{at}nifty.com Department of General and Cardiothoracic Surgery, Kanazawa University School of Medicine, Kanazawa 920–8641, Japan.
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ABSTRACT
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The Poly-L-lactide costal coaptation pin is an effective device in chest wall reconstruction. However, fixation is sometimes incomplete, despite the use of the costal coaptation pin. We report here the use of two suture techniques for the fixation of the incised ribs with costal coaptation and discuss the effectiveness of these procedures. We used the Poly-L-lactide costal coaptation pin in 174 cases of posterolateral thoracotomies with two suture methods. In one method the rib was generally fixed with suture only (L-method, n = 30), and in the H-method pairs of holes were made at the end of the incised ribs for ligating with sutures (H-method, n = 144). The effectiveness of each method was evaluated based on the degree of fixation and lateral shift 24 months postoperatively. Lateral shift was none in 114 (79.2%) cases using the H-method and 18 (60.0%) cases using the L-method. Fixation was good in 131 (91.0%) cases using the H-method but in only 20 (66.7%) cases using the L-method. H-method was significantly more effective than the L-method of costal coaptation. The H-method was very effective for fixing incised ribs and is convenient for use by thoracic surgeons.
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INTRODUCTION
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The Poly-L-lactide costal coaptation pin (P-L-LA pin) is an effective device in the treatment of fractures and osteotomies.1–4 The ribs are often incised to gain a wider operating field when performing posterolateral thoracotomy, and we have routinely used these pins to fix the incised rib in patients with posterolateral thoracotomy. However, in patients with brittle bone marrow, the P-L-LA pin is sometimes ineffective in joining two incised ribs together because the pin can move within the space of bone marrow and the outer rib suture can loosen at a costal angle. Therefore, we devised another method of fixing the incised ribs using the P-L-LA pin and report here our method and the results.
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PATIENTS AND METHODS
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One hundred seventy four consecutive patients who underwent posterolateral thoracotomy since 1994 were included in this study. We used the P-L-LA costal coaptation pin and closed the chest with two suture methods. In one method the rib was generally fixed with suture only (L-method, n = 30), and in the H-method pairs of holes were made in the end incised for ligating for sutures (H-method, n = 144). H-method was performed in 144 patients and L-method in 30 at random (Figure 1
, Table 1). The costal pins were evaluated based on the degree of fixation resulting from distraction levels in the coaptated ribs and lateral shift judged on computed tomographic findings at approximately 24 months postoperatively. The distraction level was evaluated from the distance of distraction between connected ribs. Lateral shift was evaluated using the system described by Tatsumi and colleagues: "none" if no dislocation occurred, "slight" if dislocation of up to half of a rib’s width occurred, and "moderate" if displacement of more than half of a rib’s width occurred.5
Usually the fifth or sixth rib is cut at the rib angle when a posterolateral thoracotomy is performed. During closure, a P-L-LA costal coaptation pin (Fixorbrib, Johnson & Johnson Co., Ltd., Tokyo, Japan) is inserted into the bone marrow of the cut rib. There are three dimensions of pins, 3 x 3 x 27, 3 x 4 x 27 and 4 x 4 x 34 mm, and selection is based on rib thickness. If bone marrow is hard, a bone curette is sometimes used to establish a route for the pin. L-method: A heavy suture with non-absorbable surgical sutures (2-Ethibond Excel polyester suture, Ethicon Inc.) bridges the gap between the two incised rib ends, and that suture is fixed in place on either end by a tie around the rib. H-method: Before inserting the pin, pairs of holes are made at the end of the incised ribs with a hand drill (1.6 mm Kirschner’s needle, Mini-Driver TM Electric, 3M Co.). When drilling through the rib, a spatula is placed behind the rib to prevent injury to the lung. Heavy sutures with two nonabsorbable surgical sutures (2-Ethibond Excel polyester sutures, Ethicon Inc.) are placed through the drill holes, and these sutures are tied with one on one side of the rib, and one on the other (Figure 2).
Data were analyzed using the Stat-View software package for Windows. Statistical analysis comparing the data was performed with Mann-Whitney’s U test. A p-value of < 0.05 was significant.
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RESULTS
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The postoperative observation period ranged from 21 to 27 months (mean ± standard error, 24.5 ± 0.6 months). Fixation from the distance of rib distraction was 1.5 ± 0.6 mm. There were statistically significant differences in "lateral shift" ( p < 0.05) and "fixation" ( p < 0.001) between these groups. In the H-method, there was no patient in which distraction reached 4 mm. There was no lateral shift in 114 (79.2%) cases, "slight"shift in 30 (20.8%) cases, and no "moderate" shift in any of the cases. There was no lateral shift in 18 (60.0%) cases using the L-method. Fixation was good in 131 (91.0%) cases using the H-method but only in 20 (66.7%) cases using the L-method. There were no side effects caused by the P-L-LA pin. Mann-Whitney’s U test indicated that the H-method was a significantly more effective procedure than the L-method (Table 2). All 3 patients with "moderate" lateral shift or "poor" fixation were above 70-years-old and were undergoing pneumonectomy.
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DISCUSSION
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The rapid development of video-assisted thoracoscopic surgery has prompted thoracic surgeons to perform video-assisted surgical procedures. Therefore, the number of rib incisions as a surgical procedure to gain surgeons’ field of vision has decreased. However, the procedure of connecting the ribs is an important and fundamental procedure of chest reconstruction even now.
The P-L-LA pin has been reported to be an effective device in the field of general thoracic surgery.5,6 However, if the bone marrow of the incised rib is brittle, it can be ineffective because the pin can move by respiratory thorax movement. Tatsumi and colleagues reported that distraction was present in 81 (44.0%) of 184 cases using an L-method.5 In their procedure, the sutures became loose and caused lateral shifting due to respiratory thorax movement because the pin could still move within the bone marrow by itself. Therefore, we used the H-method to fix the incised rib since we speculated it to be stronger than the L-method. The results of our study showed that the H-method was superior to the L-method physiologically with good clinical results. Moreover, the L-method poses a risk of compression of an intercostal nerve, inducing postoperative chest pain, if it is difficult to ablate the periosteum without touching the nerve. In the present study, we found that all patients who had poor results with the L-method underwent pneumonectomy. Unilateral ventilation may cause the imbalanced action of an external force on the ribs. Our H-method is widely available to reconstruct the sternum and ribs in cases of funnel chest. This method is very effective for fixing incised ribs using a P-L-LA pin and is convenient for use by thoracic surgeons.
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REFERENCES
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Clinical application of costal coaptation pins made of hydroxyapatite and poly-L-lactide composite for posterolateral thoracotomy
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510 - 513.
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